Abbeyfield Loughborough

Registration details

CQC register Abbeyfield Loughborough to carry out these legally regulated activities. Contact us if you think Abbeyfield Loughborough is operating services not listed here.

Type of service

• Residential homes

Service specialism

• Caring for adults over 65 yrs
• Caring for adults under 65 yrs
• Dementia

Local authority

Leicestershire

Monitored services

CQC register Abbeyfield Loughborough to carry out the following legally regulated services here:

Accommodation for persons who require nursing or personal care

Mrs Kerry Anne Cattell is responsible for these services.

Ms Faye Sylvia Kitson is the registered manager for these services at this location.

Miss Tracy Louise Taylor is the registered manager for these services at this location.

Condition of this registration relating to carrying out this regulated activity

The registered provider must not admit any new service user to Abbeyfield Loughborough without the prior written agreement of the Care Quality Commission. This includes any new service user admission requests, any respite or emergency admissions of service users, any readmissions of previous service users, or where service users return to the location following admission to hospital.

The registered provider must ensure all staff undertake training in Positive Behavioural Support (including sexualised behaviours), advanced and complex dementia and mental health by 31 October 2023. Evidence must be provided to the Commission by email, of staff completion and competency, including attendance sheets, certificates, course synopsis and training provider. This must include evidence that staff understand and are able to provide care that is suitable to meet the needs of service users who communicate through distressed behaviours and are trained and assessed as competent in de-escalation and breakaway techniques.

The registered provider must immediately review and action changes to their staffing levels within the home to ensure there are sufficient numbers of trained and competent staff to meet the needs of service users at all times. This review must include but is not limited to how you have ensured there is enough staff deployed to meet the current needs of service users atAbbeyfield Loughborough taking into account the following:
• Service users who require support from more than one member of staff.
• Service users who walk with purpose and because of cognitive impairment are at risk of falling, becoming disorientated or entering other service user’sprivate rooms or personal space.
• Service users who require staff support and/or prompting to protect them from the risk of poor nutrition and/or de-hydration.
• Service users who require emotional and physical support due to distress
• Service users who require support from staff to access fresh air, meaningful activities in line with their interests and hobbies and outside spaces

The registered provider must carry out a review of the governance and quality assurance and monitoring systems covering the following areas and provide the Commission with a report and evidence this has been completed by 6 October 2023. The report should include the following:
• care records reflect service user’s current needs with a process of regularly updating them.
• risks to service users are managed; all records must reflect service user’s current needs.
• positive behaviour support strategies are sufficiently detailed and information to provide guidance for staff and are regularly reviewed post incidents or in the event of changes in service users’ needs.
• safeguarding incidents are recorded, investigated and notified to relevant agencies, including the Care Quality Commission, in a timely manner
• systems and procedures to assess and monitor the quality of care provided are effective in identifying improvements and ensuring these are made in a timely manner.
• the registered provider must send to the Commission, an updated action plan on the first Monday of each month, with an initial action plan submitted within 5 working days of the date of this notice of decision. The action plan must detail the improvements has made in response and the impact those improvements have had on the quality and safety of the service which service users’ receive and should include audits of staffing levels and dependencies. This will include any proposed revision of the action plan

Terms of this registration relating to carrying out this regulated activity

The Registered Provider must not provide nursing care under accommodation for persons who require nursing or personal care at Abbeyfield Loughborough.

The Registered Provider must only accommodate a maximum of 64 service users at Abbeyfield Loughborough.